World Mime Organisation

LEGAL NAME OF THE INSTITUTION:(*)

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NAME OF THE INSTITUTION USED IN PUBLIC COMMUNICATION (if different):

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SHORT NAME and/or ABBREVIATION:

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TYPE OF LEGAL ENTITY (limited company, association, fond, theatre,…):(*)

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OWNERSHIP: Public (Government, City, Municipality…) or private(*)

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Administrative BODY and PLACE OF REGISTRATION:(*)

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Registration Number:(*)

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Tax ID Number:(*)

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DATE OF REGISTRATION:(*)

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ADDRESS:(*)

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OFFICE PHONE NUMBER:

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OFFICE FAX NUMBER:

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e-MAIL:(*)

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WEBSITEs:

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FACEBOOK, Youtube, Tweeter and/or other social media:

Facebook:

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Youtube:

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Tweeter:

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other social media:

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GENERAL MANAGER/DIRECTOR/PRESIDENT (please state the title of the position):(*)

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CELLULAR PHONE NUMBER:

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e-MAIL:(*)

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By applying for an Official Membership at the World Mime Organisation I accept to pay an Annual Membership Fee in the amount of 100 US Dollars for the whole calendar year.

IMPORTANT

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PayPal/Credit CarBank Transfer

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